NHS trust fined £200k for failing to provide safe care and treatment

The NHS trust that runs three hospitals in Brighton has been fined £200,000 for failing to provide safe care and treatment after the death of a 16-year-old girl.

University Hospitals Sussex NHS Foundation Trust was prosecuted by the Care Quality Commission (CQC) over the death of Ellame Ford-Dunn.

The case was heard at Brighton Magistrates’ Court this afternoon (Wednesday 26 November).

Ellame, from Upper Beeding, was under 24-hour one-to-one observation by a registered mental health nurse in Worthing Hospital when she absconded.

She was found dead in the grounds of the hospital an hour later on the evening of Sunday 20 March 2022.

The trust pleaded guilty to not providing care and treatment in a safe way, resulting in Ellame being exposed to a significant risk of avoidable harm.

District Judge Tessa Szagun fined the trust £200,000 and ordered it to pay prosecution costs of £25,405.70 and a victim surcharge of £190.

An inquest into her death has been opened but stands adjourned, awaiting the outcome of the criminal prosecution.

According to charity Inquest: “Ellame had a long history of trauma, suicidal ideation and self-harm. She was autistic and had ADHD and an eating disorder.

“She was under the care of Child and Adolescent Mental Health Services (CAMHS) and had spent over 18 months in inpatient mental health care units.”

The charity said that she was discharged in mid-January 2022, with a package of “aftercare”, from Chalkhill Hospital, in Haywards Heath.

The hospital, the only children’s inpatient psychiatric unit in Sussex, is due to close temporarily in the next few weeks, with no date set for the reopening.

At the end of February 2022, Ellame was informally admitted to Bluefin Ward, at Worthing Hospital, as a result of self-harm.

The charity said: “A few days later, she was detained under section 3 of the Mental Health Act after absconding from the hospital and ligaturing. She was placed under 24-hour one-to-one observation by a registered mental health nurse.”

On Sunday 20 March at 8.30pm, Ellame absconded. Security staff searched the hospital grounds before calling Sussex police.

The charity added: “At 9.30pm, police found Ellame having ligatured in the hospital grounds. An ambulance was called and Ellame was taken into the hospital where she was declared dead shortly after.

“The scope of the inquest will examine events from the time of her discharge on Tuesday 18 January 2022 until and including the events of Ellame’s death on Sunday 20 March 2022.”

The criminal case was first listed at Brighton Magistrates’ Court in early July and adjourned until Monday 27 October when University Hospitals Sussex entered a guilty plea.

The inquest is due to take place at the West Sussex, Brighton and Hove Coroner’s Court. The most recent hearing took place in late July when it was adjourned because the criminal case takes precedence.

District Judge Szagun said: “The circumstances are tragic, having resulted in the death of Ellame aged just 16.

“Nothing that the defendant organisation expressed in terms of their heartfelt apology and condolence or regret at the consequences of their accepted omissions nor any fine I impose or indeed any sentencing remarks I make can begin to make any difference to how her family have been impacted by the devastation and shock of this loss as articulately, eloquently and emotionally conveyed in the victim personal statement read to the court by her mother.

“The circumstances are not in dispute. In clinical terms, Ellame presented as a particularly complex case and a very real danger to herself.”

She should have been in a mental health bed but none were available so the trust accepted her in Bluefin ward and stepped up the level of observation.

But when Ellame left the ward, the district judge said that she should have been followed but a longstanding trust policy did not allow for this.

The same issue arose at the recent inquest into the death of Patricia Genders, known as Tricia, who died in February last year after walking out of the Royal Sussex County Hospital, Brighton. The Royal Sussex is run by the same trust.

Mrs Genders fell to her death shortly after leaving the hospital where she was under close observation. She was not followed out of the grounds, making it harder for the police to locate her before she died.

In Ellame’s case, the trust told the court that it had introduced a new missing persons policy including not just a requirement to take reasonable steps to prevent a person from leaving a ward.

It also required staff to shout for help, alert security using an emergency bleep, follow the patient and try to persuade them to return.

But if the patient left, staff should note the direction of travel and, in a case of an obvious and immediate risk of harm or where the patient is under section, notify the police.

Outside court, her father Ken Ford-Dunn said their daughter was “failed by a system that was meant to protect her”.

He also called for the money to be used by the CQC to fund children’s mental health services, which he said were in “urgent” need of support.

Mr Ford-Dunn said: “This prosecution is an important step in highlighting just one of the many failings in Ellame’s care and brings a first taste of justice on behalf of our darling girl.”

Ellame had been under 24-hour one-to-one supervision by a registered mental health nurse on an acute ward at Worthing Hospital when she absconded.

She was on that ward because there was “no alternative” and no adequate bed for her risk level was available, the court was told.

The prosecution accepted that the defendant trust was in a “difficult position” and would have had to turn Ellame away otherwise.

James Harland, prosecuting, said: “No tier four bed was readily available and the high demand for such beds is a national issue.”

Ellame would not usually have been on the University Hospitals Sussex ward but Sussex Partnership Foundation Trust (SPFT), who were assessing her condition, did not have capacity to provide her with an adequate bed.

Outside court, Ellame’s father remembered her as “a bright firework in a dark sky” and said: “The loss of Ellame has been devastating, not only for us as a family, but for her wider family, friends and all who loved her.

“There is no greater heartbreak than losing a child but to lose a child you believed was being kept safe creates a pain beyond measure and a deep searing anger.

“No financial penalty could ever feel proportionate to the destruction that has been caused.”

University Hospitals Sussex chief nurse Maggie Davies said: “When we appeared at last month’s hearing, we acknowledged the seriousness of what happened and the devastating impact on Ellame’s family and friends. That remains true today.

“The loss of Ellame was a tragedy for her and for those who loved her. Colleagues involved in her care remain devastated by her death and the impact it continues to have on her family and friends.

“We had a responsibility to protect her while she was in our care and we are sincerely sorry that we were not able to do that.

“Everyone accepts that people with acute mental illness should not be in general hospital wards or A&E departments but that does not lessen our duty to keep patients safe while efforts are made to provide them with more appropriate care.

“Since Ellame’s death, we have made significant improvements to our policies, training and ward environments to prevent anything like this happening again.

“Today’s sentencing reflects the seriousness of what happened and we remain committed to working with our NHS partners to learn from this tragedy and for us all to find better ways of caring for patients who are vulnerable.”